Ullman begins his crowing about the Swiss report with this dubious statement:

The Swiss government has a long and widely-respected history of neutrality, and therefore, reports from this government on controversial subjects need to be taken more seriously than other reports from countries that are more strongly influenced by present economic and political constituencies.

Political neutrality is not equivalent to being scientifically unbiased. Ullman, and other homeopaths, however, are keen to prefer the Swiss report over other government reports. This is because in 2010 the UK government performed their own systematic review of homeopathy – Evidence Check 2: Homeopathy. In their report they concluded that homeopathy is essentially witchcraft – that it does not work, its underlying principles are scientifically invalid and tantamount to magic, that it should not be covered by the national health service, and that it is not even worth any further research. Ullman strangely does not mention this report directly in his article.

How can two governments analyze the same question with the same set of data and come to opposite conclusions? The review of the Swiss report, by David Martin Shaw, gives us a clue. He writes:

This paper analyses the report and concludes that it is scientifically, logically and ethically flawed. Specifically, it contains no new evidence and misinterprets studies previously exposed as weak; creates a new standard of evidence designed to make homeopathy appear effective; and attempts to discredit randomised controlled trials as the gold standard of evidence. Most importantly, almost all the authors have conflicts of interest, despite their claim that none exist. If anything, the report proves that homeopaths are willing to distort evidence in order to support their beliefs, and its authors appear to have breached Swiss Academies of Arts and Sciences principles governing scientific integrity.

The data they looked at was the same – scientific studies showing that homeopathy does not work. Published systematic reviews of clinical trials of homeopathy do not show evidence that homeopathy has any physiological effect. Edzard Ernst reviewing these reviews concludes:

The findings of currently available Cochrane reviews of studies of homeopathy do not show that homeopathic medicines have effects beyond placebo.

What is very telling is that even reviews of homeopathic trials that try to put a positive spin on the data can’t help giving away the game, such as the conclusion of this review from France (perhaps the center of support for homeopathy):

There is some evidence that homeopathic treatments are more effective than placebo; however, the strength of this evidence is low because of the low methodological quality of the trials. Studies of high methodological quality were more likely to be negative than the lower quality studies. Further high quality studies are needed to confirm these results.

They are looking at the same evidence as Ernst but desperately try to focus on the positive – there is some evidence of effect. But high quality studies were more likely to be negative. That pattern is what tells the tale. If you look at the literature of any scientific question what you see is an inverse relationship between study quality and the spread of results. Low quality studies are all over the place, while high quality studies tend to zero in on the true effect size of what is being studied (in the case of homeopathy, zero). Basing any conclusions on the low quality studies is pure nonsense and an indication of bias.

Further, the low quality studies are not randomly scattered but often show systematic bias toward being positive, both researcher and publication bias. This bias can sometimes be revealed in so-called funnel plots, which graphically display the relationship between study quality and outcome.

What all this means is that if you want to actually answer the question, does homeopathy work, you need to rely upon the most rigorously designed placebo-controlled trials. Anything less is likely to reflect bias and be highly misleading. Systematic reviews generally reflect this, and the UK report on homeopathy reflected this reality – when properly studied, homeopathy does not work.

The Swiss study looked at the same data, but apparently wanted to come to a favorable conclusion. So they argued for a change in the normal rules of evidence, a common strategy among CAM proponents. They decided to rely more on “real-world effectiveness,” which is just CAM newspeak for “poorly controlled studies.” In the real world we cannot control for variables and blind subjects – those are artificial conditions of rigorous trials. Homeopaths are not the only ones to try this gambit. Acupuncturists, for example, have been trying to push “pragmatic” studies as if they were efficacy studies, which they are not (again, because they study “real-world” conditions and are not properly controlled).

In other words, this is all an elaborate deception as a means of preferring low quality studies that are amenable to a positive bias to rigorous studies that are more likely to reflect the true (non-existent) effect of homeopathy. Pragmatic studies are meant only to compare treatments that have already been demonstrated to have efficacy in rigorous trials. They are not a substitute for double-blind placebo controlled trials, and they certainly should not be used to trump the results of more rigorous trials.

In his critical analysis Shaw zeroes in on the bias evident in the Swiss report, quoting:

If homeopathy is highly likely to be effective but this cannot be consistently proven in clinical trials, the question arises of what conditions are needed for homeopathy to show its effectiveness and realise its potential, and what conditions threaten to obscure this?

In this statement they are assuming homeopathy works, but are frustrated by the fact that high quality clinical trials show that it does not work, therefore they want to find a kind of evidence that will fit their pre-determined conclusion and help them to promote homeopathy. This is what Ullman concludes is unbiased. Rather, this is a core feature of CAM and even pseudoscience in general – starting with a desired conclusion and then looking for evidence to support it.

Shaw also points out that the majority of the authors of the Swiss report were in fact homeopaths. There was only one medically qualified expert on the panel who was not a homeopath or CAM practitioner. The fix, clearly, was in. And yet they declared no conflicts of interest. Shaw is very clear in his condemnation of this lack of scientific integrity:

The ethos of the research integrity guideline is that “Scientific misconduct must not be tolerated.” In this case, it has not only been tolerated but given the stamp of approval by the Swiss government and used to inform health policy: from January 2012, homeopathy will be included in health insurance cover, contributing in part to a rise in insurance premiums of as much as 4.4%.

Conclusion

The Swiss report represents a biased review largely by homeopaths who changed the rules of evidence in order to declare that homeopathy works. Other homeopaths then present this review as unbiased and definitive. This is behavior that would make even the most unscrupulous pharmaceutical rep blush.

This is also, unfortunately, not an isolated incident. This represents a general strategy apparent in the world of CAM – to present themselves as the experts so that they can pack panels with proponents and then advocate for changing the normal rules of scientific evidence in order to produce highly biased assessments of CAM. Further, they portray skeptics (meaning those who advocate for consistent and rigorous scientific methods) to be biased so that when they point out that the emperor has no clothes they can be dismissed.

The Swiss report on homeopathy represents an embarrassing failure for the Swiss government. They should suspend any decisions based upon this report and put together an new scientific panel to perform a fresh and legitimate review of homeopathy. Or, they don’t have to reinvent the wheel – they can just review the UKs thorough and rigorous report and adopt its findings. Homeopathy is witchcraft and deserves no government support of any kind.

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114 thoughts on “The Swiss Report on Homeopathy”

No doubt this Swiss report will be used here in the states to justify its use. People will claim “see, it does work, a whole nation and its government supports it! Why don’t we?” Any evidence showed that the report is biased in pretty much every way will not sway these people, in will only reinforce them and they will retort with accusations of “BigPharma controlling the gubmint” and “doctors only want to keep the people sick.”

It may be a little out of your field Dr. Novella, but what makes pseudoscience supporters think this way? You open up with a quote saying that the Swiss is neutral (which I instantly knew that it is only neutral in political affairs, which you reinforced by stating it), how do people make these leaps in thought?

I cannot wrap my head around it. The only thing I can think of is people hold a belief and when it is held so “close” or is used to shape their lives, when exposed to contrary evidence they do not like the thought of being mislead or fooled so they reject all conflicting ideas. If this is more or less correct, I do not understand why one would be willfully ignorant.

I would rather be wrong 99% of the time, correct my errors, and understand why I was wrong than live in darkness (so to speak).

I apologize if it is a tad off-topic or appears to be a lot of questions.

It is rather strange to call this a Swiss government report. In the course of an evaluation of five alternative treatments which were being reimbursed by the Swiss public health insurance, several groups submitted reports. The Shang et al. paper (2005) was one of these reports. This book (published in German and in Germany in 2006) was another. The total result is that the Swiss government stopped the reimbursement. Only later a referendum made them reinstate it, and another round of evaluation will taken place in the future.

Ernst mostly looked at chapter 9, but I have been looking at chapter 10. Here is a summary of what I found.

Chapter 10 – written by six authors, five of whom are homeopaths – collects 29 studies in ‘Upper Respiratory Tract Infections/AllergicReactions’ (URTI/A). This number is surprisingly small. I found 161 such studies by a cursory internet search. The authors managed to miss 25 studies that had been mentioned in earlier meta-analyses. Their investigation seem to have been a haste job, as they claimed lack of time for 5 studies. They included a study of what appears to be a single case of infectious mononucleosis (their number 12). They included one study (their number 4) but missed the one by the same principal author immediately preceding it in the same journal. They missed a Mexican paper (Riverón-Garrote et al. 1998 [2]) that ‘proved’ homeopathy effective for asthma with p=0.00000000001 by my estimate. So the whole selection is haphazard and sloppy.

As small studies are unreliable and anything not a double blind RCT cannot be taken serious in homeopathy, I restricted my attention to the 11 placebo controlled double blind RCTs with more than 50 patients.

Two of these are large Oscillococcinum trials. These must be considered as dubious. The first one by Ferley et al. (1989) [3] selected of all patients with flu-like symptoms only the few that recovered in 48 hours, which happened to be the only possibility out of 14 yielding a statistically significant (correctly computed: p=0.0494) result. This can at best be considered an exploratory result of the weakest kind. A follow-up study was done (Papp et al. 1998, not in Pubmed [4]) in which the Ferley hypothesis was tested by a group led by Philippe Belon, research director of the manufacturer of Oscillococcinum. The null hypothesis could not be rejected (p=0.4). However, this result was not mentioned at all. Instead an undocumented test, the Krauth test, was said to yield p=0.0028. No details were given.

The other nine (in chronological order the numbers 8, 6, 10, 1, 4, 22, 24, 25, 29 in chapter 10) can all be found in Pubmed, and except number 6 (Reilly et al. 1986 [5]) they all returned a negative verdict: not significant, not effective, no clinical relevance, no evidence etc. The 30 per cent dropout rate in Reilly’s paper doesn’t inspire much confidence. But according to the authors of chapter 10, the majority (five out of nine) were in favour of homeopathy. An example is the research by my compatriot Elly de Lange (number 1 in chapter 10). She treated 175 kids (among whom 5 dropouts) each for a full year with classical homeopathy and for a condition (URTI) reputed to be eminently treatable by homeopathy. She found that her placebo group happened to be a little, but not significantly so, sicker than the verum group. The rather unremarkable fact that various measures of sickness (number, length and severity of sickness episodes etc.) were consistent with each other was mentioned by the De Lange et al. (1994). [6] This in its turn made the authors of chapter 10 mark this paper as showing a positive trend in favor of homeopathy.

So altogether the whole of chapter 10 is another example of the standard technique nowadays used by homeopaths: they misrepresent papers on such a scale that only the most tenaceous critics have the energy to figure out all untruths.

Thank you, Jan Willem, for that thorough addition to the post!
———–
I have the same questions as you, Jimmylegs, but no answers other than this is just the way many “believers” are wired. That’s one thing and we can’t reach them all, but for governments, well–that’s another story and a damn shame.

“What all this means is that if you want to actually answer the question, does homeopathy work, you need to rely upon the most rigorously designed placebo-controlled trials.”

(As I’ve said elsewhere) I think the homeopaths should wholeheartedly embrace this view and respond to EBM-ish claims that the CT evidence shows that /homeopathy/ doesn’t work with something like this:

“You skeptics and allopaths are anti-homeopathy biased hypocrites, sneakily using double standards in your ‘scientific’ arguments against homeopathy. A CT of any particular homeopathic remedy is only a test of /homeopathy/ in the same weak sense that each pharmaceutical drug CT is a test of /pharmaceuticals/. Edzard Ernst has said there’ve only been about 200 homeopathy CTs and that most of those have been poorly done. Even if they’d all been for different remedies, I’d guess that amounts to good evidence against only a very few (tens of?) individual homeopathic remedies.”

They cherry-pick evidence of effect by redefining evidence, and redefining effect. They assert the primacy of “real-world” evidence (i.e. “it worked for me” anecdotes) over objective evidence, which they seek to minimise by inventing new terms for it. In evaluating the data:

Instead of just formally evaluating the studies, we examined their content for bias.
Wherever this was possible on the basis of the data available we searched for bias
due to methodical deficiencies (internal validity) or whether the studies were not or
only partially transferable to our research because they inadequately reflected the
real health care situation.

In other words, the quality of evidence is recast as being the extent to which it supports their predefined conclusion.

Instead of assessing whether there is a causal relationship between use of sugar pills and cure, they ask:”Can the outcome be attributed to the intervention according to CBM (cognition-based medicine) criteria?” CBM is an anthroposophical concept and, as the authors acknowledged, not widely accepted. As in: not accepted at all other than by loons.

They assert that “The dilutions’ mode of action requires a homeopathic explanation”, in order to be able to reject the scientific fact that there is no credible mechanism of operation – a representative example of recasting every question in terms which embody the assumption that homeopathy is valid (very much like politicians rephrasing a question so as to remove the awkward bits and introduce instead an opportunity to present the party line).

Yo Hayes — yes, good quality RCTs have been done on only a fraction of the innumerable (and ever-growing) different purported homeopathic “remedies,” but that does not mean there is good evidence against only those few. In the first place, I wouldn’t care if there was evidence against some arbitrary proposition so long as there was no evidence for it; I wouldn’t even bother to look because I can make up an infinite number of claims but the only ones worth testing are those that have some plausibility. But in fact, the evidence against *all* homeopathic remedies is overwhelming because they are all physically, chemically, and biologically completely implausible and transparently nonsensical.

The FDA approval process for real medications has had its problems, but a) it’s getting better as we learn from experience and gradually make reforms to reduce conflicts of interest and publication bias; and b) if we learn, post-marketing, that a drug is either less effective or more dangerous than we thought it was, we actually change its label or even remove it from the market entirely. Homeopaths do not respond to new evidence.

I am not clear about what s/he means. In medicine, I thought, the merits of any single treatment are judged by testing that treatment on a well defined group of subjects, usually with a single disease. In this sense there cannot be a test of ‘homeopathy’. One can test a single homeopathic claim such as
– ‘blue eyed women who prefer lukewarm tea are cured of whatever ailment they have by Pulsatilla C30′ or
– ‘children with recurrent URTI will be a lot less sick, when treated by classical homeopathy in addition to usual care’ or
– ‘by means of an emanometer / dowsing rod / reproving it is possible to distinguish Belladonna 200C from Sulphur 200C’.

Of course, in the hypothetical case that many such tests favor homeopathy, one might be optimistic about the prospect of more positive tests. But even then each treatment of sick people should be separately tested.

But in the real world the reviews show that there is no single combination of a homeopathic treatmen and a disease that has been shown to work consistently.

In ordinary medicine meta-analysis and reviews refer to combinations of independent investigations of the same treatment-disease combination. Homeopathy reviews deviate from this because ‘homeopathy’ is not a single treatment, but a ratbag of many different kinds.

It also has been shown that when authors have some kind of stake (either their salary or a deeply held conviction) their research reports can be biased (at least in medicine). So reviews that politely conclude: ‘The positive homeopathy results cannot be entirely due to the placebo effect’ in fact say: ‘The positive results in homeopathy are probably caused by extreme prejudice of the researchers, resulting in many different kinds of data massage, multiple comparisons, optional stops, selective treatment of dropouts, incompetent randomizing and faulty blinding, publication bias and maybe even outright fraud.’ (Am I leaving out something?)

If one sees how seriously homeopaths are distorting what the published literature says, one cannot be very optimistic about what happens when they are left alone with the mass of data produced by their ‘experiment’ and when they have to distill a paper from it for publication.

There is one easy way to test homeopathy (not prove its effectivity), or rather one million easy ways. There are about one million claimed effects (1000 effects of 1000 remedies each) of highly diluted materials on healthy volunteers. These tests can be made without any cost. No sick people are put at risk. In fact, all over the world skeptic groups would be happy to cooperate and organise properly blinded and randomized tests. These claimed effects form the basis for any classical homeopathic prescription.

So, homeopaths, do first a few of these tests! It won’t cost you a cent. But you have to provide a clear cut claim, not one that all the 100,000 other homeopaths will deny to have any relevance. Of course such tests have been done and they all have failed. Stronger: modern homeopaths absolutely refuse to cooperate with such tests.

I conclude: as long as homeopaths refuse to do the simple tests, there is no reason to pay attention to all their claims. If they do the simple tests and fail, there is no reason to pay attention to them anymore. If they succeed they get Nobel prizes for physics, chemistry and medicine and peace, and science can move on to doing experiments with sick people.

Yo Cervantes — that’s exactly right but it’s your argument (and mine). We haven’t been led by a conflict between sound scientific ‘instincts’ and an irrational ‘system’ of inference into making transparently bogus arguments against homeopathy based on the irrelevant results of cargo cult CTs. Unfortunately, others have.

@phayes the fact is that homeopathy is implausible to the point of effective impossibility, as we all know. RCTs of drugs confirm the effect of those drugs, but also confirm the RCT as the most reliable way of establishing effect. There are few RCTs on whole classes of drugs, though, and that’s probably because the families grow by addition one by one.

What we find with RCTs of homeopathy is that they all confirm the null hypothesis. They are, I think, the only evidence that science would accept as refuting the null hypothesis if that ever happened, but none do refute it.

Homeopathy is being weighed against some of the most robust and carefully tested science there is: scientists themselves would not accept quantum theory until it was proven beyond doubt. That’s a hell of a mountain for homeopathy to climb, and the first foothill would be a robust randomised controlled trial that convincingly refuted the null hypothesis of placebo effect and experimental bias. Nope. They are still tripping over sticks on the grassy lower slopes.

This is the really important point. Everything in science, in order to be accepted, either has to be a theory that has been confirmed by multiple elegant experiments, or it must refute the null hypothesis and become fact. Homeopathy does neither. It asserts itself as based on “laws”, but these laws are predicated on a deterministic and continuous model of matter. Nothing in the theory or practice of homeopathy accounts for the difference between macro effects and quantum effects; X, C and even M potencies are all asserted to work by the same principles but at some point usually informally reckoned to be around 12C you move from the linear deterministic world of classical physics into the world of quantum mechanics – and there is *nothing at all* in the theory or tradition of homeopathy which is consistent with this. Nothing.

For a fuller understanding of the history of the Swiss homeopathy HTA, the criticism of it by the Swiss Complementary Medicine Evaluation Program (PEK in German) – at a cost of €4 million – and how it led to reimbursement for homeopathy being withdrawn, see the blog post by myself and Sven Rudloff: That ‘neutral’ Swiss homeopathy report.

But note that the published homeopathy HTA (that Steven linked to in the first line of the post) is not the HTA that the Swiss PEK evaluated – it’s been added to subsequently by its authors, including their criticism of Shang et al. The PEK had their own view of Shang et al.

The HTA was written by homeopaths for the Swiss Government and cannot be considered a Swiss Government report, but the subsequent PEK report, because the PEK is a commission set up by the Swiss Government, can.

As Jan Willem Nienhuys says, it was a subsequent referendum instigated by homeopaths (presumably because they didn’t get what they wanted from the PEK) that led to a further temporary period of reimbursement for homeopathy.

Dana Ullman said:
The Swiss government has a long and widely-respected history of neutrality, and therefore […]

I must be missing his point. Why exactly does the famous even-handed Swiss willingness to take Nazi gold deposits make their homeopathy reports believable? Is Ullman comparing homeopaths to Nazis? That is horribly inappropriate. Don’t blame me, he brought it up.

Neutrality is only a virtue in the absence of knowledge.

Novella asked:
How can two governments analyze the same question with the same set of data and come to opposite conclusions?

Someone way more awesome than me already answered this sort of question:
“How can two mathematicians come to two different conclusions? Well, one of them’s a dick.”

(Apologies to the Swiss government, in light of the apparently non-neutral information provided by Zeno and Nienhuys. That was one of those things where I couldn’t not use the quote after I remembered it.)

Also (triple post!), here’s one of the earliest signs that the report is aiming for BS:

Chapter 1, Page 2, Introduction:

HTA is short for Health Technology Assessment, an established scientific procedure which, in contrast to the meta-analysis and systematic reviews specified by the Cochrane Collaboration Standards, examines not only the efficacy of a particular intervention, but especially also its ‘real-world effectiveness’, its appropriateness, safety, and economy.

So the Cochrane standards are too strict for these people. They want to do that now-standard trick in which you conduct pragmatic studies of things which don’t work.

As Jan and Zeno have already pointed out, the fundamental context issue with this “Swiss Government report from 2011 that brought homeopathy back on the agenda” is that in fact it is “a 2011 publication of a one-sided contribution from mainly German homeopaths to a Swiss Government evaluation in 2004, which led them to *end* the endorsement of homeopathy in 2005″.

The muddled reporting is certainly partly due to the deja-vu situation in Switzerland, which currently undertakes a similar evaluation to the one from 12 years ago again, and the fact that most documents on the matter are in (Swiss) German.

There is a remark about Shang et al. that I haven’t thought up myself but I forgot where I saw it. Homeopathy (and certainly homeopathy in decent ethically approved trials) usually treats complaints for which there is no good regular treatment like hayfever or flu. Or is used as an adjunct to regular therapy (in case of diarrhea). It is not much of a surprise that if one starts looking for comparable trials, one finds trials of regular medicine for the same complaints. So it is to be expected that homeopathy and regular medicine don’t differ too much.

Among other things you’re completely missing the point. Ordinarily I’d be ‘happy’ to explain it and this (inference) stuff more fully again but it’s become a bit of a chore and recognising the name ‘Guy Chapman’ from the badscience.net forums and from comments posted in online discussions in which I’ve already done so has put me right off the idea this time. Apologies if that’s unfair and/or you’re not the same Guy Chapman.

It may be a little out of your field Dr. Novella, but what makes pseudoscience supporters think this way?

It’s no mystery. Homeopathy (etc) seems to “work” for them. They don’t want to be unscientific; they desperately want the recognition of science. The unattractive dodging and weaving derives from having o reconcile their personal experiences of homeopathy with what they themselves recognize as unconvincing results in scientific studies.

On our part all that we can say is that to the extent that homeopathic methods “work”, they do so, to a very high level of likelihood, as placebo and other non-specific influences.

We are not entitled to say that homeopathy serves no useful medical functions in these societies with strong traditions of it.

Note that no one seems able to point to harmful consequences of homeopathy in those countries.

And women can wear burkas if they “want” to (many have little to say about it), but I’m still going to tell them there are options, even ones that provide modesty.

Any kind of folk medicine may serve a function in a society, though not a legitimate medical function. The “harmful consequences” of homeopathy in ANY country is that it may stop people getting real treatment–especially children who have no control over their care. As far as I know homeopathy thrives mostly in developed societies so the “strong tradition” you cite is nothing more than the belief of reasonably educated people who ought to know better. They have the right to believe what they wish, but not to bottle and sell it for exorbitant prices. Since it’s water, they ought to give it away–people could bring their own bottle.

We are not entitled to say that homeopathy serves no useful medical functions in these societies with strong traditions of it.

Really?

Homeopathy serves no useful medical function in societies with strong traditions of it.

There. I just said it. I stand by it, too, “entitled” or not.

Note that no one seems able to point to harmful consequences of homeopathy in those countries.

Oh, really?

You mean like millions of pounds of taxpayer money wasted on remedies that are nothing but water? On constructing and running homeopathic hospitals? (As an aside, I have a rather amusing picture of myself in front of the Royal London Homeopathic Hospital taken on a trip to London five years ago; maybe I’ll post it sometime.) Are you saying that waste of money, both public and private, is not harmful? What about people who forego effective treatment for homeopathy and suffer? Or what about homeopaths claiming that homeopathy prevents influenza as well as vaccines or that it can be used to prevent malaria? Are you saying that’s not harmful?

Note that no one seems able to point to harmful consequences of homeopathy in those countries.

Perhaps you were too busy coddling CAM users to read about the case of Gloria Thomas. A newborn that died of eczema because her parents shunned legitimate medical treatment and instead utilized homeopathic quackery.

The damage of homeopathy is not in the medicine, and the number of cases of (fatal) patient’s delay is small. Of course for a treatment without any benefit any damage is too much. But one of the main harmful effects of alternative medicine is that it corrupts the mind. In the USA homeopathy is not a big thing, but in Europe it is. Homeopathy is an important contributor to a whole array of strange ideas. The Dutch physicians that practise homeopathy are not just doing homeopathy, but they also indulge in ozon therapy, live blood analysis, so-called post vaccination syndrome treatment (i.e. they are active antivaxers), kinesiology, alternatieve cancer therapy, electroacupuncture according to Voll (a combination of Abrams-style dowsing, E-meters, acupuncture and homeopathy as diagnostic instrument), biotensors, muscle testing a.k.a. applied kinesiology, bioresonance, iridology, orthomolecular therapy, Buteyko, candidiasis, medical astrology, ayaurveda, craniosacral therapy, Bach flower remedies, Mayr therapy, colon hydrotherapy, anti-aging, Lüscher color therapy, fytotherapy, various modalities of acupuncture, psychic healing, cell therapy, chelation therapy, dianetcis, enzym therapy, acupuncture… and more. There is an organisation called Homeopaths without Borders, which provides homeopathic malaria prophylaxis and teaches health workers in poor (African) countries to treat aids and other serious diseases with homeopathy.

In some countries homeopathy is the main vehicle for the introduction of all kinds of crazy and superstituous ideas about how the body works. You might compare it to the deleterious affect of creationism on science education. The analogy is closer than you think, because homeopathy has many similarities to religion: an old book by a revered prophet who claimed his method was a gift of God to humanity, many different sects, energetic proselytizing, a complicated theory of spiritual realities such as ‘the life force’. And of course the pretense that they have Healing Power, supported with many, many miracles stories and personal experiences.

How can two governments analyze the same question with the same set of data and come to opposite conclusions?

They didn’t. After looking at the evidence presented in the Bornhoft et al “Health Technology Assessment” (i.e. the original version of the “Swiss report” being discussed here), the Shang meta-analysis, and a third report about the use of homoeopathy by Swiss doctors, the Swiss government withdrew funding for homoeopathy.

As a precondition for reimbursement the physician consulted had to be fully qualified

So only physicians administering one of five treatments (anthroposophic medicine, homeopathy, neural therapy, phytotherapy
and traditional Chinese medicine (TCM, Chinese phytotherapy in particular) could provide reimbursable services. A person buying some homeopathic preparation in the drugstore or whatever a lay homeopath would do was NOT reimbursed.

Moreover, I interpret ‘fully qualified’ to mean that the physician should have had some kind of training in the technique, because one cannot call a person ‘Arzt’ (physician) unless he is qualified to practice medicine. Presumably TCM comprised acupuncture. The report does not contain any details about this.

This point is not stressed very much in discussions.

Incidentally, how many physicians (MDs) in the US practice homeopathy?

What is very telling is that even reviews of homeopathic trials that try to put a positive spin on the data can’t help giving away the game, such as the conclusion of this review from France…

But see also what one of the authors of that review said about it being used as evidence for homoeopathy:

I spoke to Jean-Pierre Boissel, an author on two of the four papers cited (Boissel et al and Cucherat et al), who was surprised at the way his work had been interpreted. “My review did not reach the conclusion ‘that homeopathy differs from placebo’,” he said, pointing out that what he and his colleagues actually found was evidence of considerable bias in results, with higher quality trials producing results less favourable to homeopathy.

We agree that homoeopathy is highly implausible and that the evidence from placebo-controlled trials is not robust. However, there are major problems with the way Shang and colleagues present and discuss their results, as well as how The Lancet reviewed and interpreted this study.
(…)The Lancet should be embarrassed by the Editorial that accompanied the study. The conclusion that physicians should tell their patients that “homoeopathy has no benefit” and that “the time has passed for … further investment in research” is not backed at all by the data. Our 1997 meta-analysis has unfortunately been misused by homoeopaths as evidence that their therapy is proven. We now find it extremely disappointing that a major medical journal misuses a similar study in a totally uncritical and polemical manner. A subversive philosophy serves neither science nor patients.

Bold face by me. So even though Linde didn’t think much of the evidence from placebo-controlled trials in favor of homeopathy and also not much about Shang et al. he criticizes homeopaths for abusing his 1997 paper.

I have read that Dutch article. There is only library in the whole of the Netherlands where one can find it. My conclusions were:

A double blind randomised trial for a homeopathically highly diluted preparation for the prevention of influenza was performed from September 1992 until April 1993. Altogether 501 subjects were analysed but an unknown number that may be as high as 499 were omitted from the study. No details are given about these dropouts. Although the verum group seemed to do better, the data are uninterpretable, for example it is unclear whether fever refers to fever days or fever periods and wehat exactly was meant by ‘fever’. How many of the patients had influenza or even flulike symptoms or reported any kind of sickness is unknown. There seems to be no primary outcome that was defined before collection of data started. The authors report several significant outcomes, but no value can be attached to the paper as a whole.

I did some calculations on the sparse data of the paper. If we assume that patients with only 1 day during which they have symptoms do not have the flu at all, then I find:

placebo:
about 8 patients had together about 20 days fever
4 patients had together 9 days muscle pain
6 patients together had 12 days headache

verum:
6 patients had together 13 days fever
1 patient had 2 days muscle pain
2 patients had together 6 days headache

(not necesarily consecutive days, the patient groups mentioned here probably overlap)
So the number of patients with real flu in the 12 weeks that they were taking the pills was really very small.

The point is that it is somewhat strange to rank this as a top quality homeopathy paper, just because the number (501) of patients involved is so high. A similar remark applies to Papp et al, which is clearly fraudulent.

You are correct that, strictly speaking, a particular RCT can only directly test a particular homeopathic remedy.

Homeopathy may be tested by examining its underlying premises, i.e. the “law” of similars and the claim that dilution makes a remedy more potent. Neither is supported by any basic science; rather they are claimed proven by the claimed effectiveness of homeopathy. (Stated a bit differently, the efficacy of homeopathic remedies is the prediction of the homeopathic hypotheses which is tested to establish the validity of said hypotheses.)

Ergo, the failure of homeopathic remedies to work DOES disprove “homeopathy,” since their claimed efficacy was the only basis for accepting the system in the first place.

The efficacy of some homeopathic remedies is the prediction of the homeopathic hypotheses which is tested to establish the validity of said hypotheses.

Ergo, the failure of all tested homeopathic remedies to work DOES disprove homeopathy.

The only thing the system of homeopathy could possibly claim as support is a record of success for the remedies prepared according to that system. No such record exists. The system therefore is unsupported by any data, and as it is inconsistent with other evidence (e.g. all of biology and chemistry), may confidently be classified as falsified.

The real reason for the distinction between pharmaceuticals as an approach and homeopathy as an approach is prior probability.

Drugs have a mechanism of action that is tested every time an adverse or main effect is demonstrated. They are biologically active molecules interacting with other biologically active molecules (organized into cells, tissues, organs and eventually organisms). So the fact that drugs (and even herbs) “work” is unsurprising, uncontroversial and well supported by (at this point) billions of observations.

Homeopathy has, in contrast, zero prior probability, no reasonable mechanism of action, contradicts multiple well-established laws of physics, chemistry and biology (this goes for homeopathy independent of mechanism, and is even worse for proposed mechanisms of action like quantum physics and the memory of water) and even lacks empirical demonstrations of effectiveness – realistically the sole test that could work to suggest there is a previously unanticipated mechanism by which homeopathy works.

Drugs fit with what we know of the body and universe in general. Homeopathy does not. But beyond this – the empirical claim rests on the claimant. It’s up to homeopaths to prove that homeopathy works, in specific and in general. Drugs have long since demonstrated empirically that their mechanism works, so now we delve into details.

I don’t think phayes is right. In the first place there are many different kinds of ‘homeopathy’.

When we stick to the classical form, it is a theory that doesn’t know any disease. The theory and ‘data’ are as follows (bare essentials)

1. The cause of almost any sickness is utterly unknown.
2. However, each sick person has a disturbance of the life force, and this disturbance manifests itself through a large number of symptoms, such as fear of thunderstorms in general, itch on the right side of the nose, sudden aggravation after dinner, grating cough (note that the minutiae of ‘cough’ runs into the hundreds of descriptions).
3. Highly diluted materials (including north pole magnetism, table salt, chalk, sand, honeybees, snake venom, pus, and lots of poisonous plants) produce many symptoms when given to healthy people.
4. Giving a highly diluted material whose symptoms are most similar to the symptoms of the sick person, will be the cure.
5. This works roughly by the artifical sickness (of the remedy) driving out the real sickness (this can lead to the so-called initial aggravation), after which the artifical sickness will vanish.

In practice it is impossible to match the hundreds of ‘symptoms’ (it takes an hour or so to determine these) of a sickness to the thousand or so symptoms of any ‘remedy’. So the homeopath is trained to somehow pick out the most important or striking ones and match these to one (out a thousand) of the remedies that has these symptoms or similar ones in the long list associated with it.

So the homeopaths don’t claim that any particular remedy can cure any particular disease. They claim their whole method can treat any disease. And if it doesn’t work, one just has search for the better ‘simillimum’.

The ‘proof’ that this is not all nonsense is:
A. the experience of Hahnemann after taking ground cinchona bark to test the way it cures ‘fever’.
B. the many examples of so-called involuntary homeopathy in the past (*)
C. the fact that highly diluted stuff always produces symptoms
D. the experience of many homeopaths that their patients get better.
E. old stories about homeopathy being better than bloodletting in cholera wards.

To describe the variants of homeopathy would take a whole book. Often homeopaths have just a few standard remedies which they match to general characteristics of their patients. Or they give Sulphur C30 for any kind of skin disease. Homeopaths who are physician will also try to establish a regular diagnosis. One kind of homeopath treats ‘autism caused by vaccination’ by giving highly diluted vaccins. Some manudfactures mix a couple of remedies together into an OTC preparation for specific indications. Oscillococcinum is supposed to prevent a specific disease.

* An example mentioned by Hahnemann and quoted by Wendell Holmes is the cobinateion of two anecdotes: a Byzantine princess revivinh her fainted brother the emperor using rose water, and the anecdote of a man fainting when exposed to a very strong rose smell. Cowpox vaccination against smallpox was considered another example.

I think the point was there is little or no evidence that homeopathy works and it’s theory is so flawed, contradicting well established facts about the world, that it has been almost completely discredited. Technically we can’t disprove that demons are the true cause of all disease, but it’s about as likely as homeopathy being a valid method of treating disease.

The details of the homeopathic theory(s) are irrelevant to my argument and this:

“So the homeopaths don’t claim that any particular remedy can cure any particular disease. They claim their whole method can treat any disease. And if it doesn’t work, one just has search for the better ‘simillimum’.”

strengthens it.

@PJLandis

“I think the point was…”

It wasn’t. It was that the claim that “the CT evidence shows that homeopathy doesn’t work” is false.

It isn’t nitpicking. Even those who don’t care about the fundamental inferential issues at stake here, will usually agree that homeopathy is bad medicine and that homeopathy CTs are an unethical waste. Surely it should also be of some concern to such people that an argument often used in the battle against these evils has a serious weakness?

I beg to differ. From the point of view of the therapists (at least the ones that are not intentionally fraudulent) it’s probably based on facts, I suspect mostly their own experience.

1. This can be because as a child their parents treated them with homeopathy. That’s the same psychological mechanism that keeps religions going on for ever.

2. It can also be that they themselves just tried homeopathy for some kind of ailment and they got better. Many strange therapeutic systems are practiced by people who have been ‘cured’ first by ity.

3. Or they started to treat others by way of experiment (out of frustration that regular medicine was powerless) and then got sucked in, for example by grateful patients.

As far as I know, nobody has systematically investigated what exactly makes homeopaths tick. I suspect that the order 1,2,3 is also the order of importance, i.e. basically it is a kind of religion.

I have heard physicians state that the study of medicine is (or used to be) utterly unscientific. The students must cram a lot of facts and are trained to slavishly follow whatever God (i.e. their professor) says. And as they at the same time think themselves the pinnacle of academe, far above the ignorant physicists and biologists and statisticians who are roughly on a par with the janitor because they don’t know the infinite variety of medical experiences, they tend to think that what these people say is quite irrelevent for actual practice – which they know of course. Maybe I exaggerate, but we are talking about the lunatic fringe of MDs.

I suppose I agree with phayes that any trial of a homeopathic remedy is not, properly, speaking a trial of homeopathy as a whole, but isn’t the point that we now have so many trials in so many circumstances that, even if homeopathy’s prior probability was not asymptotically zero, we can quite reasonably infer that homeopathy as a whole does not work. To say otherwise is to engage in a progressively more extreme search for a True Scotsman. But, even if, under some special circumstance and in some special way in a particular trial set-up, homeopathy was shown to work (again ignoring prior probability) homeopathy as a therapy is still busted because it does not claim minute effects in tiny areas of medicine, it claims huge, reliable, staring-you-in-the-face effects.

Strictly speaking any trial (or drug proving) that fails, is a failure of the whole of homeopathy, precisely because of the grandiose claims of homeopathy. Except it won’t convince any homeopath. For the individual homeopath only the personal experience counts. That trumps any scientific investigation.

Take Elly de Lange (who followed 175 URTI children for a year). Just because of the tiny and nonsignificant difference between the two groups she remained convinced that the difference was, statistically speaking the best estimate between ‘homeopathy’ and ‘no homeopathy’ and went on practicing homeopathy until the present.

Of course there are many schools of homeopathy. Some homeopaths are not really dogmatic and they believe that homeopathy shoudl be used in case no really good regular treatment exist.

There is what I call the ultra-isopathic school: to treat a disease administer a diluted form of the cause of the disease (pollen, for instance).

Some homeopaths have absorbed the one-disease-one-drug philosophy: if drug A doesn’t work for disease 1, then B, C, D, … might do the trick. Or A works for disease 2, 3, 4… This group is of course not put off by one failed RCT.

But all homeopaths crave scientific recognition, so if anything remotely scientific offers a spark of hope they shout it out: “Homeopathy irrefutably proved”, even if they have to severely distort the scientific message. Of course, when physics, chemistry, biology and pharmacology say loud and clear: ‘It’s impossible’, they don’t listen. But a misunderstood statistical test, used without real understanding of what statistics is about is immediately believed.

“but isn’t the point that we now have so many trials in so many circumstances that, even if homeopathy’s prior probability was not asymptotically zero, we can quite reasonably infer that homeopathy as a whole does not work.”

Only by explicitly doing what you’re implicitly doing there: invoking the indirect evidence (and system of inference) which does apply to the whole of it. You can’t escape the necessity to do that if you want to argue that evidence ruling out e.g. Oscillococcinum as a cure for the ‘flu has any bearing on any other remedy. But once you have invoked it you’ve invoked the evidence (and system of inference) which makes homeopathy CTs futile cargo cult science which shouldn’t have been done in the first place and whose results can be ignored!

“Strictly speaking any trial (or drug proving) that fails, is a failure of the whole of homeopathy, precisely because of the grandiose claims of homeopathy. Except it won’t convince any homeopath.”

It won’t convince me either. It’s a fundamentally illogical argument. And those grandiose claims are only grandiose in the light of the evidence which does rule out homeopathy and makes any CT’s results irrelevant anyway! As Badly Shaved Monkey pointed out elsewhere:

“200 years ago homeopathy was not, on the face of it, a stupid idea. It merited testing its underpinning claims against what was known about the world and it merited testing its actual clinical efficacy. Now it merits neither. We know more than we did then and we know homeopathy is a thing that doesn’t work.”

Dr Gorski:We are not entitled to say that homeopathy serves no useful medical functions in these societies with strong traditions of it.
Really?
Homeopathy serves no useful medical function in societies with strong traditions of it.
There. I just said it. I stand by it, too, “entitled” or not.

While everyone has chosen to interpret .me otherwise, I was saying (as was obvious enough from context) that our own science does not permit such a sweeping statement. Of course people can say it, if they choose to ignore certain matters.

So let’s start afresh. Are you, Weing, Dr Gosrki, and others dismissing placebo and other non-specific influences of medical interactions as being of no benefit to users, despite, if anything recent firming up of evidence in their favor?

Are you also unaware of the instinctive compulsions that drive much medical consumption, such that if you took homeopathy away it would be certainly be immediately replaced by potentially more dangerous CAM or folk methods? There would also be increased pressure upon conventional medical services, with the risks and costs that derive from its tendency towards over-investigation and over-treatment,and to produce adverse drug reactions.

Do you not also see how the vast majority of the relevant therapeutic episodes (within and without the mainstream) relate to extremely common, minor, chronic or self-limiting complaints for many of which scientific medicine has little to offer or offers only partial relief? If the alternative for the patient is basically to put up with ongoing symptoms, why would we begrudge patients any small (and probably occasionally strong) relief that may be facilitated by these treatment rituals, especially if they help keep people out of doctor’s offices, with all the risks and costs therof?

So I suggest that it can be scientifically , sociologically and medically problematical, as well as possibly a tactical mistake to be solely focussed upon the usual unqualified “it works” /”no, it doesn’t” argument with homeopaths. How are politicians or the public to decide between the opposing viewpoints especially when some members of the public will also be pleading that it helps them?

Why not acknowledge that homeopathy is likely to be (almost inadvertently) helping some people through placebo and other non-specific influences, but hammer home the point that dozens of other dubious medical treatments can do the same?

The true problem is that no publicly funded health care system can afford to subsidize them all, or find any clear means of selecting some, but not all. They are also optional add-ons to normal medical care, making it unfair that those who don’t want to use them should have to subsidize those who do.

There has to be a cut-off point and consistent performance in quality placebo-controlled studies is the only realistic option. If unable to perform so, let those who wish to practice or patronize these styles of medicine, do so at consumer expense, or with minimal public assistance and medical endorsement.

In support of this approach is the fact that as practiced in those countries with long experience of homeopathy working alongside the mainstream, it seems to be reasonably safe. It seems that, given time, we can largely trust the public and most homeopaths to use it in a truly complementary role to mainstream medicine.

OTOH perhaps a pragmatic compromise between good intuition and poor taste in inferential foundations is possible if you’re prepared to allow probabilities on hypotheses while still ignoring indirect evidence. Then – I suppose – you could reasonably invoke Laplace’s rule of succession and decide to rule out homeopathy for good if its probability reaches say 1/20 or less. (That would require CT evidence ruling out each of 18 different remedies).

Most placebo effects are caused by people just getting better. No treatment at all would allow those. A very small effect is caused by the treatment excluding any active material. To obtain this effect, one has to lie to the patient. While many years ago Doctors regularly prescribed placebos, now such a practice is usually frowned on.

Allowing patients to fund their own excursions into anti-medicine is not a great idea unless their freedom of choice is accompanied by freedom of information. Homeopaths certainly cannot be trusted in this area. The Swiss report is just the latest piece of misinformation to come from them. Above is a comment from Mojo showing the misinformation from the BHS.

But in general, homeopaths are anti-medicine. They recommend against medicine in very dangerous areas such as malaria prophylaxis, AIDS and cholera.

If people considering homeopathy want to help sick people, why don’t they become Doctors or nurses? If they go into homeopathy because they feel it to be more lucrative or easier or from a bias against EBM then educating people to avoid them will be a public service.

Phayes, I am not quite sure that I know what you are getting at, but do you know of any clinical studies of homeopathy that have not involved the cooperation of homeopaths? That surely implies the testing of homeopathy under the conditions in which at least those homeopaths believe it is most likely to work. Surely they would not get involved if they were dubious.

So in essence what is being tested out is whether those homeopath’s beliefs, formed on the basis of their daily clinical experiences, is reliable evidence of intrinsic therapeutic activity. Once that has been shown not to be so, and moreover now with four or five different popular embodiments of homeopathy, why would it be necessary to keep on testing any other claims based upon that now discredited evidence?

I think you are saying that the implausibility should be enough evidence in itself. That is a reasonable position but so is the view that the generally negative studies carry force beyond their actual numbers.

The essence of what I’m getting at is that Harvey Homeopath and Freddie Frequentist have between them managed to con poor old Joe Medical Scientist into making himself appear even less ratonal and coherent than they are.

“dismissing placebo and other non-specific influences of medical interactions as being of no benefit to users,”
I shouldn’t have to repeat this, but we are not dismissing them as being of no benefit. We are asking for objective evidence that they are of benefit and that the benefits outweighs the disadvantages. We are applying the same standard we apply to any claim. One could argue that heroin was not “of no benefit to users.” It makes them feel good and relieves their withdrawal symptoms. One could argue that it was OK to pay with counterfeit money because the recipient would derive some benefit at least until he was caught spending it.

“Are you also unaware of the instinctive compulsions that drive much medical consumption,”
I’m getting really tired of telling you that we ARE aware of those factors.

“extremely common, minor, chronic or self-limiting complaints for many of which scientific medicine has little to offer or offers only partial relief? If the alternative for the patient is basically to put up with ongoing symptoms,’

You are setting up a false dilemma. To repeat myself once more, good doctors can always offer patients psychological support, comfort measures, and help in coping with their symptoms and improving quality of life.

“we can largely trust the public and most homeopaths to use it in a truly complementary role to mainstream medicine.”

You are more trusting than I am. Have you forgotten the UK study where homeopaths advised customers to forgo malaria prophylaxis and use a homeopathic remedy instead? Have you forgotten the baby in Australia who died?

For someone who claims he is not an apologist for CAM, you sure do a good imitation of one!

Harriet: .“dismissing placebo and other non-specific influences of medical interactions as being of no benefit to users,”
I shouldn’t have to repeat this, but we are not dismissing them as being of no benefit.

What have Weing and Dr Gorski just said?

This is a thoroughly entrenched skeptical “trope”. It is a necessary plank of orthodox medical skepticism, because as soon as you allow that there may be benefits from the use of CAM you can no longer put zero into those cost benefit equations that we use to justify certain mainstream activities and condemn certain CAM ones.

When looking at the “CAM problem” from a cost/risk/benefit stance and a whole population perspective, as I am, then small benefits within millions of therapeutic episodes will certainly count for something, especially if also safe and helping to reduce medical costs and risks in other ways and when there might easily be a resort to something worse.

I make no apology for trying to look at these matters in a critical, wholly science-based manner (my invitation to argue that out still stands).

This forum should be thrilled that someone is trying to inject any new life at all into rather tired, old, stalled debates. Others could do that better than I, but first they will have to slip out from under certain biases and habitual modes of thought. Pseudoscience is just as vulnerable with my approach, if not more so, because it cuts the ground from under it in a way that everyone can more easily understand (at the cost? of more explictly acknowledging the likelihood of non-specific benefits).

weing said “the burden is on them to show that it serves a useful medical function.” What I said.
Dr. Gorski said “Homeopathy serves no useful medical function in societies with strong traditions of it.” I think he means that there is no evidence that health outcomes are any better in those societies. That doesn’t rule out what I think you are suggesting: a nebulous psychological or financial benefit of some sort. But you haven’t defined what you think those benefits are and you haven’t provided any evidence to support your opinion.

I allow that there may be short-term benefits in the way patients feel with CAM and with placebos, but there is no real evidence of objective benefits. It is short-sighted to seek those short-term subjective benefits without considering the longer term consequences. Just as it is short-sighted to give a heroin addict another dose of heroin.

“I make no apology for trying to look at these matters in a critical, wholly science-based manner”
If that were true, you would have presented evidence rather than contrarian opinions and criticisms of our approach.

I think phayes tries to say that homeopathy is so silly that it is a waste of energy to test it at all, and especially by doing this in expensive RCTs. There he has a point, and it is the reason why I propose to restrict tests to ‘reprovings’.

But manufacturers of homeopathic stuff and ardent homeopaths will be doing these RCTs anyway, and you know what happens when ardent believers and people with a financial stake in the outcome are going to do RCTs.

Take for example Jennifer Jacobs MD MPH. She is famous for researching the use of homeopathy for childhood diarrhea in poor warm countries. I analysed her researches.

If you look at any single of her investigations, most of them seem to support homeopathy. Here they are.

“4.” was a meta-analysis of the author’s own researches 1., 2., 3. Duh. The meta-analysis was favorable. All researches were of the type of individual classical homeopathic therapy as an adjunct to regular therapy, rehydratation. Then 5. was a large investigation. The five most popular remedies from 1., 2., 3. were combined in a tablet and given to more children then in 1. 2. 3. together. No individual counseling anymore. Incidentally completely against the teaching of Hahnemann who rather explictly forbade combining remedies. But then the research failed miserably.

How was that possible? I mean, what kind of corners were cut in the first three investigations? Comparing 1, 2 3 and 4 carefully, one sees the outcome measures changing, and in the meta-analysis gain other outcomes were used.

1. is suspiciously small (34 patients in all) and non-significant. Suspicion: when they found out it didn’t work, they just stopped and called it a ‘pilot’. It was published after the research for 2. was done.
2. barely significant and mentions 5 outcome measures. The numbers in the article are inconsistent.
3. announces that they plan to look at how long the diarrhea lasts, but this outcome measure is not reported; in 4. it is mentioned: non-significant. There are six years between the research and the publication. Paranoid types like me think that is the time they needed to rearrange the numbers until they looked ‘positive’.
4. among others, the numbers differ from those in 3., possibly because of the difference between ‘stool’ and ‘unformed stool’.

It seems that the authors have been constructing outcome measures after all data were in, and have been doing that in each investigation. Possibly they used the method of optional stop: looking at the results after every few patients: you stop as soon as you have ‘reached significance’ and also when failure threatens, but then you call it a pilot.

Moral / remedy: don’t trust research unless (a) the research plan, including planned outcome measures and number of patients
has been published or registered prior to the investigation (b) blinding and randomizing are described in great detail (c) reassurance that no decision about what to calculate and what to put in the article was taken after breaking the code.

There are many more things wrong with the research and they have been discussed on SBM, see for instance

and search SBM for the word Homeocracy. But I think (maybe it’s an illusion) that my ‘microscopy of the numbers’ hasn’t been done by others. My antiquackery friends tell me that trying to ferret out inconsistency in papers is pretty irrelevant, because it homeopathy is nonsene anyway.

But the tricks to massage data into shape are probably not confined to homeopaths. But what better way to bring out those tricks than homeopathy research? In fact, it is almost certain that these papers contain tricks, the puzzle is just to locate them. In that way you learn lessons that can help you to spot errors in ordinary papers.

In this connection I find it strange that nobody has noticed the strange use of this “Krauth test” in Papp et al.

Manual for fraud:
It is an example of how to cheat with statistics: you tabulate several highly correlated disease symptoms, and you compute the probability that they all vanish at the same time, assuming that the symptoms are statistically independent. (Take a picture of yourself throwing ‘tails'; print the picture 100 times and display them all: its shows the miracle of you throwiung consecutively 100 tiems ‘tails’.) Naturally you get a low probability. Any small random difference between verum and placebo can be blown up that way, and if you take the liberty to choose the disease symptoms too (of course after breaking the code), then you have an almost certain way to get the verum look better.

“I think phayes tries to say that homeopathy is so silly that it is a waste of energy to test it at all, and especially by doing this in expensive RCTs. There he has a point, and it is the reason why I propose to restrict tests to ‘reprovings’”

That’s just the main assumption of my point which is really about how [not] to argue for an end to such wasteful and unethical cargo cult science.

“It seems that the authors have been constructing outcome measures after all data were in, and have been doing that in each investigation. Possibly they used the method of optional stop: looking at the results after every few patients: you stop as soon as you have ‘reached significance’ and also when failure threatens, but then you call it a pilot.”

I don’t agree with a socialized health system, and I dread it here, but, if people are forced to pay through taxes for healthcare, then they should be able to choose and get the healthcare they want and pay for, which includes homeopathy. Sorry.

“Clearly understandable shorthand” for what? That the CT evidence disproves homeopathy? Then it’s the shorthand version of a simple falsehood. That the CT evidence /and/ other evidence disproves homeopathy? Then it’s the shorthand version of a fragilely incoherent argument. From my point of view you’re the one(s) making the mountain out of the molehill: an argument against the whole of homeopathy founded upon error. It may seem like insignificant nitpicking to you (and others, no doubt) but it’s precisely because little grains of sand in the machinery of logic and inference can lead to the construction of grand but fragile phantoms:http://letterstonature.wordpress.com/2010/10/26/terms-and-conditions-a-fine-tuned-critique-of-ikeda-and-jeffreys-part-1/#comment-2311 that I’m doing it.

“if people are forced to pay through taxes for healthcare, then they should be able to choose and get the healthcare they want and pay for”

What if they want heroin? What if their wants result in poor outcomes and then the rest of us have to pay for their hospitalization and other expenses? What if a depressed patient thought the only way to cheer her up was to go on a shopping spree? Should we subsidize that?

I fully agree that they should get the healthcare they want and pay for, but I don’t think they should be allowed to define healthcare to include anything and everything they might dream up!

Harriet…actually, if you look at it that way, (which I do not) but, if I did, then, if I am still forced to pay for what you consider good healthcare (which I don’t) it still stands that you should pay for what I consider good healthcare (and still do).

I don’t consider what you consider good healthcare, as good healthcare..is what I am saying..so therefore, why would I be forced to pay for it either. Therefore, it would be the only fair thing to do, for you to pay for what I consider good healthcare..and for what others consider good healthcare..whether we agree or not.

Therein would be the problem to begin with with ‘socialized’ healthcare actually. It could come down to forced ok..even a ‘fascist’ faulty system, someone else determining what any and everyone should get..or not.

if people are forced to pay through taxes for healthcare, then they should be able to choose and get the healthcare they want

In a decent system the compulsory basic health insurance usually covers a rather precisely defined collection of services, and only scientifically proven medicine, and even then not everything. It is up to insurance companies to offer supplementary insurance for added services. Unfortunately market mechanisms then lead to insurance companies to include all kinds of frills in their packages, among which alternative medicine. They don’t do that because they believe they are effective, and even not because the public wants it, but because it is a way to attract young and educated people (who will cost them less in really expensive care).

It is possible that altmed is put into the basic insurance. An example is Switzerland where the popular vote forced the government to reinstate alt-med services (if dispensed by MDs).

@pmoran,
“What have Weing and Dr Gorski just said?”
weing said “the burden is on them to show that it serves a useful medical function.” What I said.
Dr. Gorski said “Homeopathy serves no useful medical function in societies with strong traditions of it.” I think he means that there is no evidence that health outcomes are any better in those societies. That doesn’t rule out what I think you are suggesting: a nebulous psychological or financial benefit of some sort. But you haven’t defined what you think those benefits are and you haven’t provided any evidence to support your opinion.

Just about every RCT that has ever been done shows that doing something gives better subjective results than doing nothing, and that doing something extra is usually better than standard care, and yet I am the one who has to prove that dubious treatments have the potential to bring some medical comfort to many? (You yourself acknowledge such influences, but approve of them only if doctors elicit them.)

I concede that what I am exploring may not in the end matter that much for the way things wash up, just as more extreme versions of medical skepticism don’t seem to be having much impact so far either, but I still dislike the disingenuousness of some of the ways that we talk about CAM, especially when the finest ethical considerations are being used to resolve other difficulties. (I apologize in advance — disingenuousness may be too strong a word for these inconsistencies but it is the closest I can come up with right now).

CAM does pose unique and complex problems, ones we have never had to consider before, and the answers to its risks may not be be simple or intuitive as we first think.

“Just about every RCT that has ever been done shows that doing something gives better subjective results than doing nothing, and that doing something extra is usually better than standard care,”

Doing anything is better than doing nothing. Even objective results are possible. Remember the Hawthorne effect? http://en.wikipedia.org/wiki/Hawthorne_effect Productivity increased during the study, but that doesn’t mean that every business should implement the interventions they tested. In that study, returning to the original conditions also led to improvement! “Better than standard care” in a pragmatic study does not justify using a placebo treatment in our practice and telling the patient it has been proven to work better.

“and yet I am the one who has to prove that dubious treatments have the potential to bring some medical comfort to many?”

You are the one who has to define “medical comfort” and show that it is clinically significant. We can agree that it’s desirable and humane to comfort patients and help them temporarily feel better, but we disagree on whether it’s OK to misrepresent the truth to them and whether long-term outcomes are improved. Whether the ends justify the means.

Acleron: Most placebo effects are caused by people just getting better. No treatment at all would allow those. A very small effect is caused by the treatment excluding any active material. To obtain this effect, one has to lie to the patient. While many years ago Doctors regularly prescribed placebos, now such a practice is usually frowned on.

To clarify how I see the science: the closest measure we have of placebo responses is studies where placebo treatment is compared to no treatment. This eliminates spontaneous happenings and most incidental influences, yet substantial responses can still be obtained in some, but not all, studies.

What does this mean? Here is where the biases of the interpreter can produce quite different conclusions.

Those who have reason to diminish the significance of placebo influences will point to the negative studies and the overall small mean effect size of about just between 0.2 and 0.3. They will point out, correctly, that such small effects could be largely from reporting biases i.e. patients giving what they think is the right answer.

Those who factor in other evidence supporting the potential for strong placebo influences (anecdotal and laboratory studies), and who note that placebo responses woulld help explain some of the more puzzling testimonials and the remarkable durability of inherently absurd medical systems such as homeopathy will think that such studies probably reflect the low end of placebo potential. They will say that clinical trials are an uninspiring environment for the eliciting of placebo effects since if properly conducted the patients should not know whether they are supposed to feel better or not. Such studies would certainly not reflect what might be possible with a charismatic and confident practitioner.

The correct scientific answer is not for me alone to say, but probably a degree or so either side of “we cannot pronounce finally on this matter yet”. I personally think the evidence is swinging towards the latter view and that we should be prepared for that and allow for it in our rethoric and our appraisal of the true psycho-socio-medical role of CAM.

The ethical considerations only apply to mainstream doctors who choose to use a treatment method knowing it is a placebo. It does not apply to homeopaths who believe in it or to patients who may have come to rely upon homeopathic remedies for some conditions.

Also my perspective in the above relates to the role homeopathy may play in whole populations in countries like Switzerland, where every pharmacy advertises homeopathic remedies and they are probably being used in massive amounts..

Here is an extract from the main meta-analysis of placebo versus no treatment studies —

Quote —

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.
In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I2 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.
In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I2 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.
Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.
Authors' conclusions
We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Take for example Jennifer Jacobs MD MPH. She is famous for researching the use of homeopathy for childhood diarrhea in poor warm countries. I analysed her researches.

Recently I was enrolled in some graduate classes at the university where she is listed in the Public Health Department. During that time I received an email to get input on who should become the new department heard of that department. I sent them a note that the person who they choose should not allow studies going into developing countries that essentially passed out sugar pills. I made it a point to link to the SBM articles discussing her research.

Rustichealthy, do not change the subject. If you do not like the national health care system of Switzerland, then do not move there. Also, if you do decide to actually buy health insurance in the USA, it should not cover homeopathy. And please get a new hobby.

clinical trials are an uninspiring environment for the eliciting of placebo effects

I think that this is not quite fair. In many clinical trials the patients are given more attention and more explanation than usual. But when the placebo used is indistinguishable from the verum (I am not talking about “usual care”) the difference between verum and placebo is the ‘effect’. It is impossible to tell from the difference how much the placebo-effect (i.e. the difference between doing nothing at all and giving placebo). To complicate things further, one cannot easily rule out that unspecific placebo-effects don’t just add up to the specific effects, but give them an extra boost.

This extra boost outside the setting of an RCT may consist of better compliance with the doctor’s advices. I have read a theory claiming that part of the placebo-effect is caused by expectations based on positive experiences with effective medication. I don’t know if there is much evidence for this. But as the placebo-effect generally is supposed to work through things like previous experiences with physicians and medicines, attention by the physician in the form of listening well, explaining carefully and thorough physical examination, I can’t see the basis for the statement that an RCT is not conducive to the placebo-effect.

There are indeed more confounding influences than I have mentioned, including the possibility of nocebo effects in patients merely assessed, entered into the study, but then left to stew on a “waiting list” for treatment. (This is almost the only way of obtaining an untreated but truly comparable group of patients to randomize. There is no way of obtaining a truly “not handled at all medically” group.)

Nevertheless if patient perceptions are the main trigger of placebo responses, uncertainty as to whether they are recceiving an an active treatment or placebo must be a powerful dampener. Such studies are therefore not a true measure of placebo potential. We don’t yet have any study design that can do so with subjective outcomes because of the reporting bias problem.

(it is not made clear in my extract that in those studies there were three groups — an “untreated” one, one given placebo and the other a treatment being tested against placebo.)

Therein would be the problem to begin with with ‘socialized’ healthcare actually. It could come down to forced ok..even a ‘fascist’ faulty system, someone else determining what any and everyone should get..or not.

I propose that people beat themselves over the head with a 20-pound rock. I believe that this might have medical benefits for diabetics.

1. Is it “fascist” to ban this as a medical practice? Maybe. What about lunatics who want to do that to their kids? Is the government required to pay for a professional head-beater?

2. Not that you brought this up, but do you really think it is all just a matter of newage opinion as to whether or not this “works”?

Harriet: .“dismissing placebo and other non-specific influences of medical interactions as being of no benefit to users,”
I shouldn’t have to repeat this, but we are not dismissing them as being of no benefit.

What have Weing and Dr Gorski just said?

The important detail is that placebo benefits are not unique to things like homeopathy. Therefore, one can dismiss placebo effects as support for homeopathy without dismissing the benefits of placebo effects. What if the homeopath’s office is located next to a grocery store? Are we being narrow-minded if we say that homeopathy does not deserve credit for it?

There is no way of obtaining a truly “not handled at all medically” group.

1. That is only a problem if you are determined to say that homeopathy deserves credit for its placebo effects while calling those same effects confounding factors for real interventions. It is interesting to study placebo effects, but that is not necessary to rule out the validity of a medical claim.

2. Your claim that a no-intervention group for the purposes of placebo studies is not possible is probably not true functionally. A mixture of groups being told yes/no/maybe for both the placebo and the test substance can give you plenty of functional data (I don’t think I invented that, in fact I am pretty sure I first heard about it in a study presented here). And what is your point anyway? You are arguing against the possibility of evidence for your own position.

Conspicuous..I hear that regarding all kinds of gov spending …like..well, if D.C. doesn’t tax us trillion of $$ up the wazoo ..where would roads come from?? ..what about fire department?? ..um..for one….those are mostly local, and ours, along with 60% of America’s FD is Voluntary..but, in any case…so..” Someone Somewhere may take 10 rocks and smash there heads in” , and so THEREFORE we must DICTATE OUR idea of what you can and can’t do with YOUR money!! See?? See the freaking pathetic made up b.s of that excuse to dictate your agenda of what ‘healthcare’ is, and demand we all pay for it against our own will? Actually, conventional meds are very competitive like that..like, burning out people’s brains with radiation, so one can live like a zombie for a few months..but I’m going to guess you have no problem with that.

You totally didn’t understand anything I said. None of this really matters if it is federal or local.

Forgetting about the money, yes or no: Should the government allow people to have their kids’ heads beaten with rocks because the parents “believe” it to be effective for diabetes? Whether or not there is a government-funded health system is not even the issue, that is only an issue which comes up as an extension of the answer to the above question.

You seem to think there is absolutely no way to objectively decide that something is real or bullshit, or whether it is helpful or harmful, which sounds like newage nonsense. This is something I hear a lot; people prefer to deny the possibility of a difference to avoid the sometimes unpleasant work of figuring things out.

Furthermore, banning “homeopathy”, or simply refusing to pay for it, is not actually a ban on your personal behavior. You can still buy drops of water and sugar pills and swallow them. People just aren’t allowed to sell them to you on the claim that those things will cure cancer, nor should the government (under a socialist medical system) accept billing for water drops on the grounds that fake pills are a medical necessity.

ConspicuousThe important detail is that placebo benefits are not unique to things like homeopathy. Therefore, one can dismiss placebo effects as support for homeopathy without dismissing the benefits of placebo effects.

Agreed, if you are referring to homeopathy as “that set of principles under which homeopathy is practiced” but the discussion up until this point clearly related to whether the use of homeopathic remedies or practitioners can serve “useful medical functions”.

What if the homeopath’s office is located next to a grocery store? Are we being narrow-minded if we say that homeopathy does not deserve credit for it?
There is no way of obtaining a truly “not handled at all medically” group.

1. That is only a problem if you are determined to say that homeopathy deserves credit for its placebo effects while calling those same effects confounding factors for real interventions. It is interesting to study placebo effects, but that is not necessary to rule out the validity of a medical claim.
2. Your claim that a no-intervention group for the purposes of placebo studies is not possible is probably not true functionally. A mixture of groups being told yes/no/maybe for both the placebo and the test substance can give you plenty of functional data (I don’t think I invented that, in fact I am pretty sure I first heard about it in a study presented here). And what is your point anyway? You are arguing against the possibility of evidence for your own position.

I was talking generally about the complexities of clinical studies of placebo responses and indicating that they can indeed “confound” in opposite directions.

There is no doubt that if you go out of your way to induce placebo responses you will always get them. The only uncertainty is how much fo those apparent responses are due to reporting biases. In relation to that, modern neurphysiological studies suggest that are at least in part “real” physiological repsonses. Other studies have shown a morphine-sparing effect of palcebo in severe pain. Never forget that placebo theory got its main boost from the observation that saline injections could often relieve severe post-opertive pain.

Yet —while I have my own impression of what is likely to be the truth, I acknowledge that we have no final answer, and our considerations should reflect that.

the subject is the Swiss homeopathy report, in other words, how homeopaths distort the facts and the relation of this coillection of distorted fact to decisions re alt-med and Swiss public health insurance. The way the US government is spending the money of the citizens (i.e. redistributing it) and the relation of that spending to healthcare is wildly off-topic.

“modern neurphysiological studies suggest that are at least in part “real” physiological repsonses. Other studies have shown a morphine-sparing effect of palcebo in severe pain. Never forget that placebo theory got its main boost from the observation that saline injections could often relieve severe post-opertive pain.”

So you would give elmer placebo tablets or injections? What if he was allergic to the placebo?

Conspicuous..a “mentally challenged” person can tell the difference between criminal activity and humane healthcare..though, I’m not sure conventional meds can most times. Burning someone’s brains out..no matter how “sophisticated” the method is..is still criminal..it may not be rocks, but it’s just as destructive and inhumane..along with a whole bunch of other methods and medicines conventional ‘sophisticated’ ‘science’ approved methods turn out.

So, YOUR idea of what is criminal, and what is humane, and what one should choose for HC is not MY idea of what is criminal, and humane and what healthcare is. So, I say ..hey..then…YOU shouldn’t have that choice of choosing such dangerous HC methods either. see?

A report by a watchdog group has concluded that prescribed medicines are “one of the most significant perils to human health resulting from human activity.” The group based their conclusion on their analysis of the US Food and Drug Administration’s database of serious adverse events.

The report was published on 31 May in QuarterWatch, a publication of the Institute for Safe Medication Practices, a non-profit organisation dedicated to “medication error prevention and safe medication use” based in Horsham, Pennsylvania.1 It calculated that in 2011 prescription drugs were associated with two to four million people in the US experiencing “serious, disabling, or fatal injuries,” including 128 000 deaths.

See..now what do we do? YOU should determine what HC anyone gets? or..even what a “placebo” is? which seems to do far far better than your methods..according to my own experience..see my website People choose to buy what they choose to buy for healthcare. Now conmeds..through government control are going to decide that? YOU should determine what HC I get to choose? ..considering the above, I think con-meds should ‘rethink’ their own ‘humane’ ideas, and stop trying to dictate to anyone else what it is, until they do. That’s the problem with gov dictating anything for anyone (other than what is blatant abuse…i.e. Rocks/Burning Brains out…etc.) unfortunately, conventional meds have succeeded in putting off a lot of their inhumane dangerous treatments as ‘sophisticated’ and acceptable. That’s a serious problem in my opinion.

(the subject is the Swiss homeopathy report, in other words, how homeopaths distort the facts and the relation of this coillection of distorted fact to decisions re alt-med and Swiss public health insurance. The way the US government is spending the money of the citizens (i.e. redistributing it) and the relation of that spending to healthcare is wildly off-topic.)

Actually, it’s not, since Feds have written a 2400 page HC Bill determining what HC is, and what we pay for and what we get now. And, we’re now forced to pay for.

In fact, this now… reminds me of an earlier time…:) when they (those in control of gov..along with the approval of the people who voted for it!) chose what was ‘science’ approved HC, for millions!, and what others were ‘forced’ to pay for with their money (and lives) …amazingly interesting…and frightful.

Should the government allow people to have their kids’ heads beaten with rocks because the parents “believe” it to be effective for diabetes?

No, ..neither should the government allow people to have their brains burned out (sophisticated machinery or not), or take chemically poisoned medicines..that have proven to kill 100’s of 1000’s each year.

Conspicuous…and, just to show the difference. You took one, hypothetical, made up, I’d say totally ridiculous example to use to represent all alternatives, (only a mentally deranged person would think up to do) (though I don’t know nor endorse all alternatives) See my “What’s the Harm Rethink” and I’ve given you exact examples of what conventional meds use as perfectly accepted ‘healthcare’!…which does cause fatalities and abuse year after year. And, you’re going to dictate to me what is right and what isn’t.

“The report was published on 31 May in QuarterWatch, a publication of the Institute for Safe Medication Practices, a non-profit organisation dedicated to “medication error prevention and safe medication use” based in Horsham, Pennsylvania.1 It calculated that in 2011 prescription drugs were associated with two to four million people in the US experiencing “serious, disabling, or fatal injuries,” including 128 000 deaths.”

Did that organization report how many strokes and deaths were prevented by the anticoagulants? Did they report how many dying of cancer were given more time on this earth from the carboplatin? Did they even tell you that there were over 120 million ER visits? If they didn’t, they only gave you half the story.

Why are we discussing it here then? Are you all Swiss?…We’re talking about government/conmeds determining what is “legitimate” healthcare and what isn’t…and I’m saying..considering the track record of con meds..you all need to think twice about dictating what is and what isn’t legitimate healthcare.

weing:

Everyone should have their choice of healthcare…that’s your conventional health care..not my choice of healthcare..however you try to defend it. I prefer we ALL pay for our own healthcare choice..and not have others determine..dictate..what is legitimate…is my point. .we all have the right and should have the freedom to determine this..especially since we’re all being forced to pay for it.

“Everyone should have their choice of healthcare…that’s your conventional health care..not my choice of healthcare..however you try to defend it. I prefer we ALL pay for our own healthcare choice..and not have others determine..dictate..what is legitimate…is my point. .we all have the right and should have the freedom to determine this..especially since we’re all being forced to pay for it.”

You can pay for your quackcare yourself. That’s your choice stemming from your own ignorance. We can’t do anything about that. That doesn’t make quackcare legitimate. But if you end up in an ER requiring legitimate care, we are forced to provide it to you despite your stupidity. Sorry, but you are not the one who determines what is legitimate. You can only decide whether you want it or not for yourself. So, when you are deathly ill and don’t want legitimate care, don’t go to an ER.

weing….I have health insurance ..to cover emergencies..I don’t expect vitamins to prevent a broken leg or a car accident..or some such. I actually know that. Those who don’t have insurance, and go to ER for free HC are usually illegals..who will continue to do so. This hc bill does nothing about that. Now my premiums have gone up, and up, since. I do pay for my own healthcare otherwise..and have gotten better, for being placebos and all, it’s amazing how good I am at it.

(and if Rusti does end up in a ER, I think it would be prudent that she not reveal her username accidentally by posting from a smart phone, since one of those taking care of her might actually read SBM!)